One morning, I went with two colleagues to Haiti’s direction of epidemiology in order to collect information for a research project. As we enjoyed some local coffee with a familiar executive at his office, he instructed us about “the good old days of disease surveillance in Haiti”. This is how he referred to the era where people from remote communities themselves reported cases of malaria to concerned authorities. They would cross through villages to identify people who were suffering from fever in their homes, he said in a melancholic tone. The past years, my research works allowed me to learn, through such anecdotes, about the systems we have set up to observe the dynamics of diseases in Haiti. While he spoke, I observed with no great surprise that the walls of the office were garnished with many US CDC (Centers for Disease Control and prevention) logos. But I couldn’t help wondering in my deeper self, how can global efforts learn from Haiti’s history of epidemiologic surveillance.

While there are many definitions for epidemiologic surveillance, the authority for this matter in the US- which is the CDC– considers it as the continuous collection of health information and their dissemination to stakeholders in order to make public health decisions. This process lies at the heart of a common commitment that some countries and institutions made in 2014, through an initiative called the Global Health Security Agenda. They work to ensure a level of preparedness to face global health threats similar to the Ebola epidemic that happened in Western Africa from 2013 until 2016. Local surveillance and global security are thus intertwined.

In Haiti, although the US military used sanitary surveys to assess the country’s situation during the 1915 occupation, a site-based surveillance system has been created only in 1990, thanks to the support of various NGOs. In fact, these organizations have been operating in Haiti since the 1950s. But soon after a coup-d’état exploded in September of that same year, the deteriorating political situation has occasioned an abrupt halt in foreign aid, crippling the public health surveillance system. Later, foreign partners supported the Haitian Institute of Childhood in relaunching the surveillance of the following conditions : malnutrition, vaccine-preventable diseases, diarrhea, acute respiratory infections and cholera.

The Direction of Epidemiology, Laboratory and Research where I was discussing with my colleagues, is now in charge of epidemiologic surveillance. The CDC and a couple of NGOs are its partners and help bring modern diagnostic tools and technologies and contribute to the training of public health professionals. The cooperation with the CDC was crucial in the aftermath of the earthquake in 2010- because many infrastructures were destroyed- and the introduction of cholera, months later. Moreover, it allows for the surveillance of polio, malaria, tuberculosis, HIV infection, respiratory diseases among other diseases and the launch of a bio-safety laboratory recently. It is worth mentioning that some NGOs run independent surveillance systems or activities whose priorities are not necessarily aligned with Haiti’s vison. From the 1990s to this day, such foreign entities have played a major role in Haiti’s epidemiologic surveillance. It has resulted in a lack of sustainability and State ownership over that matter.

This history hence raises the question of Haitian sovereignty. How can foreign actors intervene so largely in this sector ever since epidemiologic surveillance started here? Who set the priorities? How does availability of international funds affect it? In fact, with progressing globalization, sovereignty can no longer be assessed through the lenses of the past centuries world, marked by violent conquers. Some common issues call for a shared responsibility and thus comes a shared sovereignty. But such interdependency does not have to favor the donors and leave the beneficiary of aid vulnerable. It needs to respect and promote local culture, language, history and institutions. As Dr. Nahid Bhadelia put it in a tweet, “the global health security agenda is as much an insurance for the resource rich world as it is for the global south… We need to address the question of inequity in trade and how we support development of stable national governance.”

And we can’t “technicalize”/medicalize all solutions. We need to address the question of inequity in trade and how we support development of stable national governance (though US has no moral high ground on that right now!)

This is the ultimate lesson Haiti’s experiences of disease surveillance can bring to the current global efforts even though the country is not a member of the security agenda. While it soon passed midday, I cheerfully thanked our host at the office for his hospitality and the coffee. What I learned beyond the malaria anecdote and through the days following that conversation, is that Haiti’s epidemiologic surveillance has always been an object of foreign influence, although such entities perform on a global scale. At times, it was left vulnerable. But with respect to Haiti’s identity, the limits can be overcome for a globally healthy future.

I often recall the days when René was hospitalized in Cap-Haitian’s hospital Justinien. What had him bedridden was a rare bacterial infection known as necrotizing fasciitis (or flesh-eating disease) which means that his right leg’s soft tissue was quickly dying. His daily wound care was particularly painful because a doctor or nurse had to unstrap his sticky bandage and clean all along under his skin, with no painkiller prior to or during the intervention. René used to scream his lungs out. In developed countries, patients are admitted to a specialized unit for such procedure and are given morphine (a common opiate) for pain relief. That wasn’t a chance available to René and many other patients who presented with acute conditions such as road injuries or bone dislocation. The lack of strong painkillers also affects chronically ill patients and those requiring palliative care. Patients dying from gastric cancer could suffer unbearable pain in their last days, relying only on first line painkillers. According to a study conducted in 2015, analgesics of all kind are available only in 63.8% of health centers in Port-au-Prince. When opioids are available, their use is strongly regulated.

In Haiti, a collaborative initiative led by the Pan-American Health Organization is responsible to create a national list of essential drugs among which analgesic opioids are listed. They also procure from international market at low cost and distribute them through State-run institutions and programs and registered-NGOs, under regulation from the national department of drugs and pharmacology. In most institutions, prescription and acquisition of morphine requires filling a special record cart detailing the patient’s information, reasons to use the drug and the prescribing doctor’s signature. It helps to promote a rational use of such medicines. Despite these mechanisms, a parallel and less regulated market of pharmaceuticals has developed in Haiti which exposes people to unsafe products. However, there’s close to no empirical evidence that opioid drugs are sold over-the-counter on the street market or that over-prescription of such drugs is prevalent at large scale.

A deadly opioid epidemic in the United States, with no doubt, rings a global alarm, but opioid drugs are much needed for acute and palliative care in Haiti where they are lacking.

It doesn’t mean that misuse and addiction to opioid drugs never occur in Haiti. This is why appropriate education is mandatory to mitigate such serious risks. Medical and pharmacological associations and societies in Haiti have the duty to address the use of medicines, train doctors and nurses and communicate in effective and innovative ways with the population. A deadly opioid epidemic in the United States, with no doubt, rings a global alarm, but opioid drugs are much needed for acute and palliative care in Haiti where they are lacking. On the other hand, fear-mongering statements made by influencers have the potential to alter trust in regulatory efforts to promote a rational use of opioid drugs and put patients at greater risks. To maintain or regain that trust might be a new challenge for the national department of drugs and pharmacology of Haiti.

Lately, a spotlight has been placed on the United Nations in Haiti. Outgoing Secretary-General, Ban Ki-Moon has delivered pivotal statements at the General Assembly and via the Miami Herald concerning the UN’s response to the cholera epidemic in Haiti. Right now is as good a time as any to remember the critical work that has already been done to eliminate the disease, long before Ban Ki-Moon’s big statement. Right now is as good a time as any to remember the fact that Haiti’s future lies only in our own hands.

Before 2010, cholera, which mostly affected Asia and Europe centuries ago, did not exist in Haiti. It was imported from Nepal in October 2010 because of the continuous dumping of feces into a river by UN peacekeepers based in Meyes, near Mirebalais, in central Haiti. Weak hygiene and sanitation conditions since the beginning of the last decade, partly due to political instability, facilitated the rapid spread of the disease to the rest of the country. This shows the UN’s direct responsibility in the emergence of the disease in Haiti, a claim which epidemiologists have backed, and which the UN has fiercely denied and hidden over the last few years.

In 2016 the United Nations has suddenly changed their posture in regards to their role in the spread of cholera in Haiti and their response to the epidemic. The first hint at this change of heart came in a report by Philip Alston, a UN adviser criticizing the organization for its disastrous response. “The UN’s explicit and unqualified denial of anything other than a moral responsibility is a disgrace,” he stated. In early December this year, 6 years and thousands of deaths later, Ban Ki-Moon apologized to the Haitian people for the role his organization played in bringing cholera to Haiti.

In his Miami Herald Op-Ed, Ban Ki-Moon revealed the outline for what he called a “new approach to right a wrong” in Haiti. This approach revolves around intense response to outbreaks, reparations to the victims’ families, and long term development strategies to provide safe water to the population. As a physician familiar with the Haitian government’s already laid out plan to eliminate cholera by 2022 and the ongoing instrumental work of human rights advocates to hold the UN accountable, I struggled to find what was new about this proposal. Is the UN simply publicly parroting the existing national plan to eliminate cholera, or are they finally heeding the victims’ unceasing call for justice?

At the beginning of 2013, while the United Nations was still denying responsibility for the outbreak, the Haitian government with support from various international partners, initiated a 10-year cholera elimination plan, with a short-term component ending in 2016. At the time, many criticized this plan as being too broad. Among other things, it aimed to guarantee access to drinking water for 80% of the population. That was quite impossible in the planned timespan, given the lack of resources.

In fact, in 2014, Haiti came close to eliminating cholera. Were it not for repeated cases of vandalism on water systems in several regions among other factors, the strategies put in place would have been successful. The Ministry of Public Health and Population (MSPP) and the National Direction for Drinking Water and Sanitation (DINEPA) have learned from these experiences, and launched the mid-term part of the plan in August 2016 (before the UN’s change of stance ) with support from partners including UNICEF. This part focuses on axes similar to what Ban Ki-Moon introduced as the UN’s new approach: water and sanitation, healthcare services and management, epidemiological surveillance, health promotion, hygiene and nutrition.

While he did acknowledge the ongoing efforts against the cholera epidemic, the public health orientation Ban Ki-Moon outlined in his op-ed is not different from what has been laid as the basis for every actor in the national plan. His proposal uses the language and solutions proposed by advocates that the UN spent the last 6 years denying. Looking back, the path we have traveled in this fight is paved with lessons for Haiti as well as for the world. The General Assembly has agreed to support the new plan to eliminate cholera in Haiti, but I will not forget where the crucial work began and continues. As I continue my travels through various Haitian communities as a Haitian public health researcher or for personal activities, the notion that Haiti’s future lies only in our hands will remain a dear mantra.

Many thanks to Nathalie Cerin for the fantastic editing of this article.

The rain was pouring as the car rolled towards Hinche. Kal and I were leading a team of doctors and researchers on a week-long investigation of factors related to the cholera epidemic in Haiti’s Center department a few weeks ago. As we went along the road, we could only look as far as five meters ahead due to heavy rainfall. I vaguely recalled hearing of a Hurricane Matthew forming in the Atlantic Ocean a few days before. The rain beating down on the area known as the “Bas Plateau” (Southern region of the Center) gave me a glimpse of the massive environmental and health consequences such a hurricane would bring to Haiti. My anxiety increased knowing that this specific department was the first, and one of the most severely, affected by the cholera epidemic ever since it was introduced in Haiti in 2010 due to improper waste management by UN peacekeepers.

Hurricane Matthew mostly devastated Haiti’s Deep South, affecting nearly 80% of homes in Jeremie, a coastal town in Grand Anse. Crops, livestock and drinking water systems also perished. As foreseen by health authorities and the population, outbreaks of cholera, which is endemic in Haiti seem to have quickly risen in several localities of the South peninsula. In light of my experience on the field in the Center, I propose a few strategic insights pertaining to cholera elimination in the aftermath of this disaster.

Decision making and public health interventions are more likely to be successful when they include members of the community served.

That is to say, the people from there who hold an attachment to that particular region, who maintain hope in the face of adversity and challenges as in post-Matthew Haiti. In my opinion, the water and sanitation technicians of the municipalities known as TEPACCs embody this idea. They are residents of the respective communities they serve. Oftentimes university students or local professionals, they are responsible for listing water sources and oversee the management of sanitation structures in the most remote areas of the country. The TEPACCs are widely responsible for the safety of the water consumed by most of the population and ensuring that waste is properly disposed.

These workers are familiar with all the localities and their physical and structural characteristics. During our time in Mirebalais, the TEPACCs Grandin and Cameau, guided us to the remote areas, and informed us on the unspoken truths of these places where cholera has remained for 6 years. The cholera efforts and results all around the country would be far more effective if they were provided the necessary equipment they often lack such as, motorcycles so they can access remote areas easier, computers and cellphones to facilitate communication. In the aftermath of Hurricane Matthew because so many water sanitation structures have been destroyed, offering more resources to the TEPACCs is crucial.

The epidemic situation in the Center also reveals the vulnerability of specific regions where cholera persists in Haiti. Floods may have worsened the contamination of water sources in the South, as shown by more than four hundred suspected cholera cases, unconfirmed as of this writing. However, the focus should not be taken off previously identified zones of cholera persistence such as specific towns or regions in the North, Center, Artibonite and West even when they were not the strongly affected by Hurricane Matthew. Studies show that these zones of persistence play an important role in re-emergence of cholera during the rainy season because the transmission lingers even during the dry season. The increased cases during the rainy season such as the situation in Randel (South) right now- where an outbreak erupted even before the hurricane- is nothing but a mere consequence of cholera enduring in Haiti for 6 years. So, in addition to the added risk that Hurricane Matthew brought, these preexisting persistence zones remain the pressure points on which our attention should remain if we hope to eliminate Cholera on the island.

The reconstruction of water systems and protection of sources should indeed take into account these towns whose vulnerability have not decreased after Matthew. In Mirebalais, I visited a Cholera Treatment Centre (CTC) where there were more than a hundred cases in the last three days at the time of my visit. An officer of an international organization working with outbreak response teams on the field reminded me that the epidemic had been raging long before the hurricane. It is imperative that we do not forget that.

La Theme River. Photo credit: Karolina Griffiths

In such a context, I do not share the opinions of some of my colleagues who dismiss the importance of vaccination, thinking it would be a waste of time, money and energy. As a matter of fact, the World Health Organization pledged one million vaccine doses to Haiti that 500,000 people could benefit from. Vaccinations may not the cure to the epidemic, but they can help save precious time and resources while we focus on strengthening our response capacity to outbreaks, improving access to safe water and sanitation, and educating at-risk populations especially in a post-disaster context. Education is crucial for behavior change, because many still believe that “cholera is spread through the air.” One man told us these words right before he nonchalantly dove in the Artibonite River that visibly contains dirt and sewage from the marketplace, the slaughterhouse and the prison.

The effects of Hurricane Matthew will be long term. The challenges of eliminating cholera by 2022 are uncountable. Based on my experience in research on the determinants of the cholera epidemic in the Center department alone, I foresee the benefits of strengthening the TEPACCs in their role, keeping epidemiologic surveillance in known areas of cholera persistence in Haiti and seizing this opportunity to vaccinate at-risk populations to prevent new cholera infections. This will be a heavy task, but this is a time where we, as a people, cannot afford to sink into fatalism or complacency. Hurricane Matthew is surely a step back, but it is also an opportunity to push Haiti forward towards progress and sustainability.

When we first moved to our current neighbourhood ten years ago, the sides of our impasse was occupied by poorly maintained shrubs and houses isolated from each other. Only one car could manage to go through a narrow path left between the trees. Acquaintances often quipped about us living in such a remote place, hardly accessible and sometimes dangerous, given the numerous cases of kidnapping that had occurred there in the past. Indeed, the main avenue was not even fully concreted and huge potholes spread along the road. But ever since the earthquake hit, people from diverse and unknown backgrounds have settled on unfenced lands nearby, slowly changing the settings. Retail sale of clairin, a popular alcoholic cocktail, has flourished since then and round the clock gambling also attracts many young unemployed. Gun related and gender specific violence were quickly added to the picture, outlined by injuries, addiction and mental health issues.

Over time, we got used to the times when drunken men cause inconvenience and to the days when quarrels over money or marriage issues block access to our home. But as an extreme example of how unchecked violence has spread, three young men were recently found dead on the streets, killed by heavy gunfire heard during the night. Surprisingly when it comes to violence, young people seem to be the most vulnerable. Violence claims the lives of 200,000 young people per year worldwide and represents the 7th cause of death in Haiti.

The disastrous political context of the country during the last decades has shaped the minds towards believing that violence is inevitable. Not only have people engaged in violent acts for the smallest rewards, but many accustomed to political turmoil think of violence as a substantial part of their daily life. The general public and the policy makers consider violence more as a banal indicator or trend, going up and down but never as an issue plaguing their own personal and community health. In our communities, the trivialization of violence is in fact, the result of inaction which results in more violence, repeating a vicious cycle and accumulating into increased cases of serious injury, chronic diseases and perhaps lowered life expectancy.

The popular culture has long encouraged violence against women through apologies of machismo and the objectification of women. It goes without saying that despite women’s rights activists’ campaigns, they remain the largest target of verbal and physical violence. Misogynistic words being too often valued and praised, they somehow abound in the media, accompanied by degrading images of women and hateful mocks. Even in my youngest years growing in Cap Haitian, the tendency to disregard women and LGBT communities’ values had already been deeply rooted in most boys my age. So it was not surprising that, as a medical intern in Cap-Haitian decades later, I couldn’t keep count of the cases of gender-related violence registered in the emergency service. There were even cases where serious burns were the consequence of such domestic violence.

Besides the factors mentioned above, structural violence seems an even more important cause of physical violence. The lack of education, unemployment, social and economic inequalities, exclusion, gender-based, racial or religious discrimination and poverty among other factors stand as complex mechanisms preventing many people from defining and fully realizing themselves. In the countryside, the absence of an efficient mean to uphold justice leaves enough space for violent conflicts over land tenure, often leading to deaths. Although there are no excuses to violence, it is rooted in a highly unequal society, which leaves very little opportunities through decent jobs and an environment to realize one’s potentials. As a matter of fact, the World Health Organization referred to concentrated poverty, easy access to alcohol, drugs and guns and weak governance as main risk factors for youth violence. And as far as we know, the daily lives of most occupants of cluttered neighborhoods in Haiti consist of much of these factors.

Although the population may rejoice in the brutal murder of robbers, these acts may not be more than a Band-Aid on a deep wound, if the core problems remain unaddressed. Perhaps it would be useful to keep engaging all communities proactively in order to expel the idea that violence is normal and inevitable in Haiti. Communication should counter the idea that the situation is acceptable today simply because it was worse 12 years ago, because no level of violence is suitable. It will be mandatory, to teach or keep reminding our communities the fact that women are equal to men both in their body and their mind. School children should be taught that violence makes orphans and leads to many health consequences. If young people are offered the opportunity to play a role in their country’s path to development, if they are able to support their families with dignity and respect for others’ property, it will certainly make a difference and that is definitely a worthy investment for the future.

The day was coming to its end as I was dealing with annoying paperwork at an outpatient clinic in the area of Delmas, in Port-au-Prince. The attending nurse sharply knocked at the door and introduced me to Zoune, a woman in her mid-forties. Calmed by the fan in motion, the ambient heat hardly bothered on this particular afternoon. Even though January hasn’t seen any rain yet, puddles and piles of rubbish in the streets form a sure cottage for mosquitoes. The tropical temperature also stimulates their reproduction. Zoune presented clinical features of the Zika disease, urging me to initiate a symptomatic treatment based on my judgment and order a few screening tests. Ever since the confirmation of Zika cases in Haiti by the Health Department (and even before) the public carefully monitor themselves for signs of the disease and inquire with their doctor. Of course some prefer to get themselves treated with simple non-pharmaceutical interventions.

The Zika virus disease is transmitted by the bite of Aedes mosquitoes, infected by the virus. Identified in humans for the first time in 1952 in Uganda and Tanzania (Emerging point of Chikungunya virus which caused an outbreak in Haiti in 2014), it spreads especially in Africa and tropical countries. This non-fatal disease involves a febrile syndrome associated with lumbago (pain in the lower back), simulating Chikungunya or malaria which is endemic in Haiti. The emergence of Zika virus disease was foretold long before its introduction in Haiti. Climatic conditions punctuated by global warming as well as migration have positively contributed to its emergence.

Currently, one can refer to an epidemic in Haiti since Zika was simply non-existent across the territory. Even though it’s relatively simple to limit its spread- provided that hygiene and sanitation measures are met- difficulties particularly arise on this level. How to involve most of the people in this dynamic? Proactive communication is the first step in management of an epidemic. But between the limited resources and the outright flaws in the Haitian healthcare system, the public is far from being reassured. Communication weaknesses have already started to plague the good management of this outbreak, hence affecting trust even more. As a matter of fact, the confirmation notice of the presence of the disease in Haiti came late compared to expectations of the people who observed that it was rapidly gaining ground and awaited a word from the Ministry of Health.

According to my observations, the greatest fear of the public lies in the eventual complications of the Zika virus disease; mainly brain malformation in newborns and Guillain Barre Syndrome which causes paralysis of the body. Although scientific literature hasn’t confirmed any link between these complications and Zika yet, in some countries where Zika spreads, women are warned to delay pregnancy or to avoid areas affected by outbreaks. In the United States, the Centers for Disease Control and Prevention have elaborated guidelines for the screening of pregnant women by gynecologists. Some see this as a unique opportunity to revive the debate on abortion in countries where a modern law is lacking. But at the time of writing, no campaign whatsoever is officially launched in Haiti thus, no warning regarding pregnancy or increased promotion of contraception services has been issued by the Health Department. The public is therefore facing the fear of this epidemic with the feeling of being on their own.

In order to foster behavioral changes necessary to protect lives, it’s important to know the perceptions and existing practices of the population. A never-ending conversation with the public allows effective management and is worth more than sparse and scant monologues in times of panic. During the Chikungunya outbreak in 2014, the organization I co-founded integrAction was delighted to share ideas and experiences with the socio-medical staff of the Haitian Red-Cross (many of whom were infected) in Cap-Haitian during a conference. This initiative helped the organization conceive groundbreaking campaign with appropriate health communication to raise awareness via social media on the disease and the means to cope with it.

On a broader scale, the current turn of public health history is an opportunity to consider reinforcing leadership capacities from the bottom to the top, while investing in research and improving the public’s health literacy. For most of the population, there’s more fear than harm as in the case of Zoune. So engaging the people through proactive communication followed by prompt action is one of the best ways to halt the spread of Zika and its potential consequences. As they express much disappointment, the Haitian people can only hope for less vulnerability. But if today’s duties are unceasingly postponed, the future, undoubtedly, can only be more grim.

A health worker fumigates the Altos del Cerro neighbourhood as part of preventive measures against the Zika virus and other mosquito-borne diseases in Soyapango, El Salvador January 21, 2016. REUTERS/Jose Cabezas

Founded in 1703, Mirebalais is a small commune situated in the Plateau Central, approximately 60 km Northeast of Port-au-Prince, the capital of Haiti. Birth place of the Haitian combatant Benoit Batraville, it is a 88.899 inhabitants, vivid locality where agriculture and livestock are predominant despite the many difficulties of commerce and daily life. Fortunately, the Peligre’s hydroelectric dam, opened 59 years ago in the Centre department, provides energy to the whole city. I first visited the town five years ago, immediately after the 2010 earthquake, with a team of medical students who volunteered at the hospital Bon Sauveur of Cange (village located near Mirebalais) run by the international NGO Partners in Health and local sister organization Zanmi Lasante.

In this 330 square kilometers town, five years later, a surgical team led by Dr Henri Ford, Haiti-born renowned surgeon, successfully separated six-month-old abdominal conjoined twin sisters. Being the first of its kind in the country, the successful operation marked a turning point in the history of Haitian medicine. This prowess, which took place at the recently erected University Hospital of Mirebalais, has drawn many insights on Haiti and the future of medical cooperation among which: the benefits of global health and surgery for the resource-limited country, the need for a paradigm shift in international medical cooperation and the opportunity to share an accurate image of Haiti.

Marian’s surgical team wore red bandanas, while Michelle’s wore yellow ones as they worked in an HUM operating room on Friday, May 22.Source: Partners in Health

Let’s consider first, the benefits of global heath and surgery for Haiti. Defined as the area of study that places a priority on improving health and achieving equity in health for all people worldwide, global health stands as a common ground, where international and local health professionals perform together in order to overcome enormous challenges usually unconquerable by a sole performer. As noted, surgery can help reduce the burden of disease by 11-15% globally, but unfortunately, the poorest people have little access to surgical care for malformations and pregnancy-related conditions like it was the case for Ketan, mother of the conjoined twins Marian and Michelle Bernard. In a context of economic insecurity and shortage of medical professionals, global health and global surgery, in Haiti, can be considered as one of the most accurate vehicule to strengthen the health care system by providing affordable access to care and sharing of knowledge and experience in the respective fields. The separation of the conjoined twins at the University Hospital of Mirebalais is a typical experience of the opportunities provided by surgery used in a context of global health.

These open doors consequently foster the need to look at the future through different lenses. They emphasize the vision that the new way of considering international medical cooperation should privilege sustainable partnership over mere assistance. This paradigm shift, in the case of Haiti, may come very gradually. Hence, the need of courageous visionary people here and abroad to challenge the status quo and be the change they want to see. The surgical prowess of Mirebalais is undoubtedly a milestone in the future of medicine in Haiti. It offers a fresh look on what is possible here where weaknesses are overly pictured. In the path of Dr Anténor Miot who introduced orthopedic surgery in Haiti, the vision and work of pioneers will definitely have an astonishing impact in the future. Not only will it lead to better care for the Haitian people but it will also propel a more accurate image of the country which is striving to build a resilient health care system.

In fact, as of the early years following the earthquake, Haitians recognized the need to share a new and appealing image of Haiti in the global scene. It comes in reaction to negative news, often spread by international medias through shocking headlines and repulsive photographs, emphasizing the state of poverty of the western part of the Hispaniola island. In the context of the separation of the siamese sisters, Haiti has retained a new kind of attention. There was extensive media coverage both prior and after the surgery by the Haitian newspaper Le Nouvelliste and international medias. The Huffington Post and CBS News among others have instantly released the positive news of the successful seven-hour surgery. As Dr Jon Lapook, CBS News chief medical correspondent, present at the event, stated “This is a country that’s trying to rebuild the health care system”. In fact, since positive changes are happening home, positive feedback will surely counteract destructive attempt.

Ultimately, leadership can be defined as the ability to inspire people to dream more, to accomplish more and to be more. It is a matter of influence through innovative ways to look at the world. No matter the field of action, no initiative will be sustainable without the necesssary amount of cooperation and knowledge sharing between people of different academic and cultural background. Therefore, the majestic surgery of Marian and Michelle Bernard at the University Hospital of Mirebalais has cast a bright light on Haiti’s future particularely in medicine despite the remaining challenges. It also outlined the power of taking impactful initiatives inside to bring a positive image outside of Haiti. In 2010, as I assisted my first surgery at Cange, I couldn’t imagine that such an astonishing event would take place at Mirebalais, little town where we used to stay not more than a few hours, the time to jump in a bus to Port-au-Prince. Next time you come across the astounding country of Haiti, make sure you pay a visit to the Hospital of Mirebalais which stands today as a cornerstone where history was written.

Manoucheca Ketan holds her conjoined twin daughters before their separation at University Hospital in Mirebalais, Haiti, on Friday, May 22.Source: Partners in Health